The entire hospital is under a microscope.
Thursday night, Duke responded.
The circumstances surrounding and related to Santillan's death have become a real public relations issue for the hospital. The latest piece of negative news is in a report from Medicare and Medicaid Services, which is critical of Duke in the wake of Santillan's death.
Instead of getting combative over the findings, Duke leaders are cooperating.
"There's some things we need to improve," Duke Hospital CEO Williams Fulkerson said.
Fulkerson doesn't refute many of the deficiencies identified in the report.
The problems eventually led to Dr. James Jaggers transplanting a heart and lungs that didn't match Santillan's blood type.
She died after a second transplant. The report states the facility failed to provide medical leadership in transplant surgical services that would ensure a consistent and patient-safe solid organ transplant program.
Failure to correct the problems could result in Duke losing critical federal funding.
"I suspect in a worst case scenario it could affect our ability to care for patients," Fulkerson said. "But that will not happen."
Fulkerson said Duke has begun instituting a series of checks and balances to prevent a similar mistake.
The Santillan famili attorney, Kurt Dixon, said that if Jesica's family decides to sue, the report should be admissible in court.
"We have a very good idea that numerous places in the chain had broken down," Dixon said, "and it wasn't just Dr. Jaggers who failed to check the blood type.
"This is not a one-and-done investigation. In fact, Division of Facility Services investigators are back again this week, and they're not just looking at the transplant center. They're looking at operations throughout the entire hospital."
"Whatever issues that they find, we will change them if we need to to come into compliance," Fulkerson said. "If we should come into compliance, we will change them, and I guarantee you; we'll be in compliance."
Fulkerson said he hopes the changes Duke is making in its system will serve as a national model to improve the transplant system.
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